Self-Management for Persons with SMI in a Behavioral Health Home
Jaspreet S. Brar, MD, PhDSenior Fellow, Department of Psychiatry, WPIC &
Community Care Behavioral Health, Pittsburgh, PA&
Suzanne Daub, MSW, LCSWSenior Director of Physical Health / Behavioral Health Integration
Community Care Behavioral Health, Pittsburgh, PA
Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.
Session #: A2aOctober 17, 2014
Faculty Disclosure
Please include ONE of the following statements:
• We have not had any relevant financial relationships during the past 12 months.
Learning Objectives
At the conclusion of this session, the participant will be able to:
1. Identify the similarities and differences between two models of behavioral health homes.
2. List the central component’s of the Wellness Coaching model used by Community Care Behavioral Health
3. Discuss the structure of Self-Management in the Wellness Coaching Model, including the roles of the Wellness Coach and the Person-In-Care
4. Learn of web-based Self-Management Resources
Bibliography / Reference
Lorig, K., Holman, H., Sobel, D., Laurent, D., Gonzalez, V., 2012, Living a Healthy Life with Chronic Conditions: Self-Management of Heart Disease, Arthritis, Diabetes, Depression, Asthma, Bronchitis, Emphysema and Other Physical and Mental Health Conditions. Fourth Edition. Bull Publishing Company, Boulder, CO.
Bartels S, Desilets R. Health Promotion Programs for People with Serious Mental Illness (Prepared by the Dartmouth Health Promotion Research Team). Washington, D.C. SAMHSA-HRSA Center for Integrated Health Solutions. January 2012.
Mrazek, P. J., & Ritchie, G. F. (2012). Becoming a Preventionist: Making Prevention Part of Your Mental Health Practice; A Continuing Education Course. Alexandria, VA: National Association of State Mental Health Program Directors (NASMHPD).
Reardon, C., 2010. Integrating Behavioral Health and Primary Care - The Person-Centered Healthcare Home. Social Work Today, Vol. 10 No. 1 P. 14.
Swarbrick, M. (2010). Peer Wellness Coaching Supervisor Manual. Freehold, NJ: Collaborative Support Programs of New Jersey, Institute for Wellness and Recovery Initiatives.
Learning Assessment
• A learning assessment is required for CE credit.
• A question and answer period will be conducted at the end of this presentation.
Health Homes: A One Stop Shop
Superb Access to
Care
Patient Engage-ment in
Care
Clinical Infor-
mation Systems
Care Coor-dination Team Care Patient
Feedback
Publicly Available
Infor-mation
Triple Aim: Improve Outcomes, Reduce Cost, Improve Patient Experience
Health Homes: A Vehicle for Integrating Care
Patient-Centered Medical Home (PCOM)
– Moving from physician-centered care to involving all members of the healthcare team (“Reinvent Primary Care”)
– Patient at the center of care
Embedding behavioral health services in medical settings
– Behavioral Health Consultant
Behavioral Health Homes (BHH)
– Improving the capacity of behavioral health settings to support physical health challenges
– CCBH model: Use of a Wellness Coach / Health Navigator
The Community Care Experience Initially 2 agencies in North Central PA in 2009 11 agency added in 2013 (PCORI), 10 additional in 2014 Wellness Nurse at each agency Wellness coaching training for nurses and case managers Used the IHI’s Learning Collaborative model for implementation Population-based care + Use of a disease registry Outcomes monitoring Case conferences to support best practices Self Management resources
Components of the Community Care Model
Wellness Coaches Nurse Case Manager Peer Specialist
Wellness Coaching training Self Management Toolkits Member Registry
Key Pharmacy and BH data Tiers 1 and 2
Development of connections with Primary Care Support of Psychiatrists
Wellness Coaching
Developed by Peggy Swarbrick, PhD at the CSPNJ Institute for Wellness and Recovery & UNDMJ
Help persons-in-care to identify strengths, needs and areas to improve, maintain or create
Clarify the person’s priorities
Establish a clear and specific goal (SMART goal)
Brainstorm action, steps and methods to support the person’s goal achievement
Set accountability, steps, including a time frame
What is Self-Management?
Carrying out health-promoting or (disease) risk-reducing activities and behaviors by persons with with chronic conditions
Self-management activities are: Activities that people can do by themselves Problem-based and Self-tailored
Self Management areas:Healthy Weight Smoking CessationPhysical Activity Taking Medications Effectively
PH/BH Care Improving SleepStress Reduction
Wellness Coach’s Role in Self-Management Engage persons-in-care in an exploration of wellness and
physical health. Support person-in-care’s effort in identifying self-
management goals (Physical Wellness Satisfaction Scale).
Case Manager’s Role in Self-Management Review cognitive strategies
Involving information processing (i.e., learning, reasoning, problem-solving, and decision making)
Review behavioral strategies The manner in which one functions and behaves
Tasks and strategies: Must be doable May involve modification of existing everyday tasks or
learning new tasks May address the specific area either directly
or indirectly
Case Manager’s Role in Self-Management Review strengths, needs, and barriers
– Strengths: personal strengths for person-in-care• Have control over practice of task or strategy?• Enjoy the activity or past history?• Can share experience with a friend or family member?• Access to resources?
– Needs: needs for person-in-care• Needs additional information?• Necessary tools? (weighing scale, pedometer, etc.)
– Barriers: anticipated problems in carrying out tasks• Not able to carry out the task/strategy?
Case Manager’s Role in Self-Management
Assist persons-in-care in identifying resources
(more later)
Facilitate the use of these resources by persons-in-care
Explain the Web-based tools (Community Care’s Member Portal) and support its use
Support person-in-care’s efforts to carry out self-management strategies
Measure the effect of self-management on specific area(s)
What is the Role of the Person-In-Care?
Choose an area for self-management (7 areas)
Select one or more tasks or strategies presented by the case manager
Number of tasks or strategies can increase incrementally
Review the tasks or strategies with the case manager in order to understand how the task or strategy is practiced or carried out
• Set a goal (S-M-A-R-T goal)
– Example: I plan to lose 3 pounds of weight in the next month by walking 1 mile 3 times a week, cutting down sugars and reducing portion size
• Develop a plan to carry it out
• Implement the plan
• Monitor how the plan is working
• Adjust plan as needed
What is the Role of the Person-In-Care?
Self-Management Resources
Other resources at the behavioral health provider’s facility
Resources at the area hospital(s) Special consultation for example dietician
or nutritionist Local community centers, grocery stores, service
clubs (i.e., Lions, Rotary, Kiwanis) Parochial/faith-based organizations, churches, etc.
Self-Management Resources
• Flip-Charts and guides1. Significance
Significance/relevance of the specific area for self-management
2. Self-management tasks & strategiesCognitive, behavioral, and other strategies for self-management
3. Resources
Self Management ResourcesSteps of Hope
Self-management support and educationhttp://www.ccbh.com/healthchoices/educational/stepsofhope/index.php Recovery educational
materials Tobacco cessation
materials Weight management
materials
Wellness Resources External websites
http://www.ccbh.com/healthchoices/educational/wellness/index.php Healthy Weight & Physical Activity Taking Medications Effectively Improving Sleep Quitting Smoking Preventive Health Care Stress Reduction Diabetes, Hypertension, Dyslipidemia COPD and Asthma Hepatitis C and HIV Traumatic Stress Heart Disease and Stroke